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Nursing homes and long-term care facilities, where 182,000 Americans perished during the covid pandemic, nexium and yeast infections have taken heat from government regulators, residents and their families. Now the industry is hearing it from an unexpected source: their investors.

Investors who own large shares of nursing home companies now are demanding that the operators improve staff working conditions and the quality of care.

Nearly 100 investor groups that manage $3.3 trillion in assets in the U.S. and abroad told nursing home companies in a recent letter that they should increase staffing levels, boost staff pay, offer paid sick leave, improve resident safety programs and allow staff members to unionize.

It's the latest pressure for reform of the nursing home industry, which has come under fire for an epic failure in infection control that spread covid-19 killing residents and staffers across the U.S.

The move by investors was unexpected, since it could reduce their financial returns. But they are worried about the future of the nursing home industry, which experienced a death wave inside its facilities that accounted for 34% of the nation's covid toll. That's not good for business.

"These are great principles that aren't necessarily in the best financial interest of investors," said David Grabowski, a health care policy professor at Harvard University who studies long-term care. "But it's hard to know if this has any teeth."

Nursing home industry groups themselves have called for reform, but they stress the need for higher Medicaid payment rates.

The investors' statement of expectations was sent to major for-profit companies and real estate investment trusts that own nursing homes, including Genesis HealthCare, Ventas, Brookdale Senior Living and CareTrust REIT. It was signed by large investor groups including BMO Global Asset Management, Aviva Investors and the Interfaith Center on Corporate Responsibility.

"This is a moment to say, 'Look at what happened during covid. You don't want it to happen again,'" said Christy Hoffman, general secretary of UNI Global Union, a labor-affiliated group that organized the investors' letter. "These workers are treated so badly, and that led to so many unnecessary deaths."

Nursing home care aides, who provide most of the hands-on care, earn about $12 an hour. Mostly women of color, they often work at more than one facility to cobble together a full-time schedule. That increased covid transmission among facilities. These workers generally don't get health benefits or paid sick leave, forcing them to come to work even when ill. Few are in unions, which have pushed for stronger safety protections. Annual turnover in the industry occasionally hits 80%.

There were reports across the U.S. that nursing homes did not provide adequate personal protective equipment like face masks and gowns to their workers, had too few workers on duty to properly care for residents, and engaged in shoddy infection control practices such as putting residents with and without covid in the same rooms.

BMO Global Asset Management already has contacted 13 nursing home companies and REITs urging appropriate staffing levels, improved health and safety standards, proper use of PPE, fair wages, pandemic hazard pay and freedom to unionize, said Nina Roth, director of responsible investment at BMO.

If they fail to meet the expectations with reasonable speed, her investment group, which manages or advises on $755 billion in assets, may take shareholder actions against management and ultimately divest from the companies, Roth said.

The American Health Care Association, which represents for-profit nursing home companies, said in a written statement, "We appreciate seeing investors taking a considerable interest in the quality of care and workforce challenges." But it added that for nursing homes to offer more competitive wages and benefits, they need "more reliable resources" from federal and state governments.

While higher payments would help, said UNI Global's Hoffman, nursing home companies "have a responsibility to do right by their workers regardless of public policy. We just don't want companies to say they'll do it when the government tells them to do it."

Advocates for nursing home residents say that, if government payment rates are increased, new transparency rules should require nursing homes to show that the additional funds are used for increased staffing and improved services, not for profits or higher salaries for executives.

In line with that, the investors' statement of expectations called on nursing home companies and REITs to publicly disclose whether they are complying with the staffing and quality-of-care targets.

Grabowski said the investors' letter shows they recognize the inevitability of nursing home reform in the wake of the covid catastrophe and want to get ahead of the wave. "They're thinking, 'Why don't we be more transparent and improve quality, or else what comes from the government could be ugly.'"